NCG160172 DMR SW (5)

STORMWATER DISCHARGE OUTFALL (SDO)
GENERAL PERMIT NO. NCG160000
DISCHARGE MONITORING REPORT (DMR)
CERTIFICATE OF COVERAGE NO. NCG1600 '� R
W, '
--------- -- -- - - -- --- ----
FACILITY NAME��
PERSON COLLECTING SAMPLES
CERTIFIED LABORATORY t't ';M' Lab #
Lab #
Monitoring Requirements
I
SAMPLES COLLECTED DURING CALENDAR YEAR: (1 �
(Thus monitoring report is due at the Division no later than 30 days fro"i � 41 2015
the tacthty receives the sampling results from the laboratory )
COUNTY _
PHONE NO.
Cfm1 HAL RLES
r)1A/rn n.
Outfall Date 00530 00400
No. Sample Collected, Total Rainfall, Total Suspended Solids, ing/l pH,
mo/dd/ r inches Standard units
00556
Total Petroleum Hydrocarbons, mg/I
EPA Method 1664 (SGT -HEM
Benchmark - - 100 Within 6.0 — 9.0
15
1A
N.LA
It a value is to excess of the benchmark, or outside the benclunark range (for pI-I), YOU must implennent the Tici I or Tier 2 responses to the General Permit
Mail original and one copy to:
Division of Water Quality
Attti Cential Files
1617 Mail Service Center
Raleigh, Noah Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify, under penalty of law, that this document and all attachments, were prepared under my direction or supervision in accordance with a system designed to
assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or'
those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
I am aware that there are significant penalties for submitting false information, including the possibility of tines and imprisonment for knowing violations."
L:P:i
(Signature of Permittee)
i g f�;
(Date)
SW U-25 2-05 1 409
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